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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600459
Report Date: 01/14/2025
Date Signed: 01/14/2025 06:04:10 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/14/2025 06:04 PM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:NEW LIFE RESIDENCEFACILITY NUMBER:
415600459
ADMINISTRATOR/
DIRECTOR:		CAMACLANG, TINAFACILITY TYPE:
740
ADDRESS:976 NORTONTELEPHONE:
(650) 579-1131
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6CENSUS: 5DATE:
01/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Deborah Jennings and TIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds of this 1-level home, consisting of 6 client bedrooms--all with half bathrooms and exit doors--1 staff room, a common bathroom, shower room, kitchen and living/dining room. There is an enclosed patio and backyard. Washer and dryer are located in 2 car garage. No accessible bodies of water or fire safety hazards observed. PPE supply is inspected. Food supplies are maintained. A comfortable temperature is maintained, lighting is sufficient for comfort and safety and hot water temperature tested at 118 degrees. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Liquid soap is available at all sinks. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 5 residents present and 2 staff. Two residents receive hospice services. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, including current first aid training and health screenings. Genny Flores is a RCFE administrator (x 1/25) that has submitted education certificates in October 2024 for renewal of administrator certificate.

The following information/forms are requested to be submitted to CCLD BY 1/21/25:

- Facility Floor Plan (LIC999 including all bathrooms)
- Proof of current liability insurance



Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/14/2025 06:04 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/14/2025 at 04:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: NEW LIFE RESIDENCE
FACILITY NUMBER: 415600459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/14/2025
Section Cited
CCR
87465(h)(2)

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INCIDENTAL MEDICAL CARE
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met, as 2 bottles of Vit D3 stored in common
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Vitamin D3, acetaminophen and Vit C relocated to inaccessible storage area in LPA's presence.
Deficiency corrected and cleared
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bathroom,and acetaminophen and Vit C stored in kitchen cabinet, where items are accessible to residents. Licensee failed to ensure that medications are stored where inaccessible to clients, which poses an immediate health, safety or personal rights risk to clients in care.
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Type A
01/14/2025
Section Cited
CCR87309(a)

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STORAGE SPACE AND ACCESS
The licensee shall ensure that disinfectants, cleaning solutions, poisonous substances... and other similar items which could pose a danger to residents are in locked storage and are not left unattended...
This requirement is not met, as Windex is
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Bottle of Windex was removed from common bathroom in LPA's presence and secured.
Deficiency corrected and cleared in LPA's presence.
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stored in common bathroom cabinet, accessible to clients. Licensee failed to ensure that cleaning solutions are secured, which poses an immediate health, safety or personal rights risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


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Document Has Been Signed on 01/14/2025 06:04 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/14/2025 at 04:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: NEW LIFE RESIDENCE
FACILITY NUMBER: 415600459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/21/2025
Section Cited
CCR
87468.1(a)(13)

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PERSONAL RIGHTS
Residents in all RCFEs shall have the personal right to have access to individual storage space for private use.
This requirement is not met, as personal items belonging to staff are stored in closet in client room #3. Licensee failed
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Personal belongings of staff will be removed from clients' rooms and proof of correction to be sent to CCLD BY DUE DATE
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to ensure that residents' closets are limited to residents' personal items, and not used by staff. This poses a potential health, safety or personal rights risk to clients in care.
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Type B
01/21/2025
Section Cited
CCR87633(b)

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HOSPICE CARE OF TERMINALLY ILL
A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include specific information. This requirement is not met, as there is no hospice care plan maintained for client #3, including use of half bed rails.
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Hospice care plan for client #3 will be sent to CCLD BY DUE DATE, and shall include order for use of half bed rails.
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Licensee failed to ensure that hospice care plan is maintained for all hospice clients, which poses a potential health, safety or personal rights risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


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Document Has Been Signed on 01/14/2025 06:04 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/14/2025 at 05:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: NEW LIFE RESIDENCE
FACILITY NUMBER: 415600459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/21/2025
Section Cited
CCR
87303(a)

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MAINTENANCE AND OPERATION
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met, as discarded
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Ceiling was temporarily covered in LPA's presence.
Discarded items will be removed from premises and proof of correction to be sent to CCLD BY DUE DATE
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furnishings are observed in backyard--table, chairs, bed frame, 2 bicycles, scooters, shelf--and pipe and insulation are exposed in room #6 as a 3' x 18" section of ceiling is missing. This poses a potential health, safety or personal rights risk to clients in care.
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Type B
01/21/2025
Section Cited
CCR87457(c)

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PREADMISSION APPRAISAL
Prior to admission a determination of the prospective resident's suitability for admission shall be completed & shall include an appraisal of their individual service needs...
This requirment is not met, as appraisals for
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Appraisals shall be completed, signed and dated for 4 clients, and copies will be sent to CCLD BY DUE DATE
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clients #2, #3, #4, #5 are missing or incomplete. Licensee failed to ensure that all residents have completed, signed and dated appraisals on file, which poses a potential health, safety or personal rights risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


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Document Has Been Signed on 01/14/2025 06:04 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/14/2025 at 05:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: NEW LIFE RESIDENCE
FACILITY NUMBER: 415600459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/15/2025
Section Cited
HSC
1569.185(e)

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HEALTH AND SAFETY CODE
The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license.
This requirement is not met, as licensee has failed to pay annual licensing renewal fees
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Annual licensing fees and late charges totalling $1979 will be paid BY DUE DUE DATE.
Proof of payment/correction to be sent to CCLD BY DUE DATE.
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for 2023, 2024 and 2025, which poses an immediate health, safety or personal rights risk to clients in care.
Licensee was reminded to pay licensing fee on 1/30/24 during annual visit.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


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Document Has Been Signed on 01/14/2025 06:04 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/14/2025 at 05:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: NEW LIFE RESIDENCE
FACILITY NUMBER: 415600459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/21/2025
Section Cited
HSC
1569.69(b)

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HEALTH AND SAFETY CODE
Each employee who received training and passed the exam required in paragraph (5) of subdivision (a)... who continues to assist with the self-administration of medicines, shall also complete 4 hours of in-service training on medication-related issues in each
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Staff who handle clients' medications will receive at least 4 hours of annual medication training. Proof/plan of correction to be sent to CCLD BY DUE DATE.
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succeeding 12-month period. This requirement is not met, as all staff have not received 4 hours of continuing medication training, which poses a potential health, safety or personal rights risk to clients in care.
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Type B
01/21/2025
Section Cited
HSC1569.696

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HEALTH AND SAFETY CODE
All RCFEs shall provide training to direct care staff on postural supports, restricted conditions or health services, & hospice care as a component of the training requirements specified in Section 1569.625. The training shall include...
4 hours of training thereafter of in-service
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Staff #3 and #4 will received required training on postural supports, restricted health conditions and hospice care. Proof of training to be sent to CCLD BY DUE DATE.
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training per year on the subject of serving those residents. This requirement was not met, as staff #3 and #4 have not received this training for 2024. Licensee failed to ensure that all staff receive required training, which poses a potential health, safety or personal rights risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


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